Monday, July 13, 2015
Contoh Pengisian Form VISA Studi (Residence) Taiwan
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擬申請何種簽證(WHICH
CATEGORY OF VISA ARE YOU APPLYING FOR ?)
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國籍(Nationality)
INDONESIA, REPUBLIC OF (印尼)
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DOMESTIC ID No.
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申請館處(Select
Where You Will Be Applying For Your Visa.)
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Asia-亞洲
Taipei Economic and Trade Office in Surabaya
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種類(Category)
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停留簽證(Visitor
Visa) 居留簽證 (Resident Visa) 外交簽證
(Diplomatic Visa) 禮遇簽證
(Courtesy Visa)
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入境次數(Number
of Entries)
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單次 (Single) 多次
(Multiple)
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申請人資料
APPLICANT'S DETAILS
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姓(Surname)
(if no,please leave blank) |
名(Given
Name(s))
(if no,please leave blank) |
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中文姓名(如有)Chinese
Name (If Any)
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舊有或其他姓名 Former
or Other Name (If Any)
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舊有或其他國籍(如有)Former
or Other Nationality (If any)
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身分證號(ID
No.)
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性別(Sex)
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男(M) 女(F) 其他(X)
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出生日期(Date
of Birth)
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1986/9/15
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年Y 月M
日D
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出生地點(Place
of Birth)
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市(City/State
or Province)
國(Country) |
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父親姓名(Father's
Full Name)
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父親出生日期(Father's
Date of Birth)
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年Y 月M
日D
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母親姓名(Mother's
Full Name)
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母親出生日期(Mother's
Date of Birth)
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年Y 月M
日D
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婚姻狀況(Marital
Status) (Diisi sesuai kenyataan)
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職業(Occupation)
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STUDENT
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服務機關或就讀學校(Name
of Employer or School)
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預計在台停留住址及電話號碼(Address
and Telephone Number in Taiwan)
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住(Address):
電(Telephone Number): |
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本國住址及電話號碼(Address
and Telephone Number in Home Country)
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住(Permanent
Address):
電(Telephone Number): |
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目前住址及電話號碼(Current
Address and Telephone Number)
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住(Address):
電(Telephone Number): |
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電子郵件Email
(if any)
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申請人護照
APPLICANT'S PASSPORT
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護照種類(Passport
Type)
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外交(Diplomatic)
公務(Official)
普通(Regular) 其他(Other)
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護照號碼(Passport
No.)
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發照日期(Date
of Issue)
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效期屆滿日(Date
of Expiry)
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發照地點(Place
of Issue)
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訪台行程
JOURNEY TO TAIWAN
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訪台目的(Purpose
of Travel)
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旅遊(Tourism)
洽商(Business)
就學(Study) 應聘(Employment)
依(探)親(Joining
or Visiting Family) 宗教
(Religion) 其他
(Other)
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是否曾經獲發過中華民國簽證？(Have
you ever been issued an ROC Visa ?)
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Yes No (Diisi sesuai kenyataan)
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抵台日期(Date
of Arrival in Taiwan)
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Diisi tanggal kedatangan
(Kira-kira)
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預定離台日期(Proposed
Date of Departure)
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Diisi 1 tahun setelah
tanggal kedatangan (Kira-kira)
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在台關係人(親友、應聘機關、就讀學校、實習機構等)
DETAILS OF YOUR CONTACT IN TAIWAN (FAMILY, FRIEND, COMPANY OR SCHOOL) |
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關係人姓名(Name)
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Diisi nama teman/ kerabat yang tinggal di Taiwan. Jika tidak ada, diisi nama orang yang menandatangani LoA/ surat penerimaan di kampus tujuan. |
與申請人關係(Relationship
to Applicant)
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Diisi sesuai kenyataan |
在台關係人之身分證字號或外僑居留證號碼(ROC
ID/ ARC No. of Your Contact in Taiwan.)
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Diisi sesuai kenyataan |
在台關係學校/機構名稱(Name
of School or Company)
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Diisi sesuai kenyataan |
住址(Residential
Address)
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Diisi sesuai kenyataan | ||
電話號碼(Telephone
No.)
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Diisi sesuai kenyataan |
電子郵件地址(Email
Address)
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Diisi sesuai kenyataan |
35.外籍配偶請填下列資料(IF YOU
ARE AN R.O.C. CITIZEN'S SPOUSE, PLEASE ANSWER THE FOLLOWING)
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是否為外籍配偶?(Are
You an R.O.C. citizen's spouse?)
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Yes No (Diisi sesuai kenyataan)
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請據實回答以下問題PLEASE
ANSWER THE FOLLOWING QUESTIONS TRUTHFULLY (Diisi sesuai kenyataan)
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Yes No
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A.是否在中華民國境內或境外曾有犯罪紀錄或曾遭中華民國政府拒絕入境、限令出境或驅逐出境？
Do you have a criminal record within or outside the territory of the R.O.C. or have you ever been denied entry, ordered to leave or deported by the R.O.C. government? |
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Yes No
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B. 是否曾非法入境中華民國者？
Have you ever entered Taiwan illegally? |
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Yes No
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C.是否患有足以妨害公共衛生或社會安寧之傳染病、精神病,或吸毒或其他疾病或吸毒成癮者？
Have you ever had a communicable disease of public health significance, a dangerous physical or mental disorder, or been a drug abuser or addict? |
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Yes No
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D.是否曾在中華民國境內逾期停留、逾期居留或非法工作？
Have you ever overstayed a visitor or resident visa or worked illegally in Taiwan? |
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Yes No
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E.是否曾從事管制藥品(如毒品)交易？
Have you ever been a controlled substance (drug) trafficker? |
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Yes No
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F.你是否曾遭中華民國駐外代表機構拒發簽證？
Have you ever been refused a visa at by an R.O.C. mission abroad? |
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Yes No
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G.是否曾以其他姓名申請中華民國簽證？
Have you ever applied for an R.O.C. visa using a different name? |
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Yes No
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H.是否曾在中華民國境內工作？
Have you ever worked in Taiwan? |
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對以上任何一項的回答是「是」並非自動表示沒有資格獲得簽證。如果你的回答是「是」，或對任何一項有疑問，最好請你親自來面談。如果現在不能親自來，請另備書面說明與申請表一齊提出。
Attention : Answering YES does not necessarily mean you are ineligible for a visa. If you answer YES to any of the above questions or if you have any questions in this regard, please come to discuss the issue in person. If you are not able to file the application in person, please prepare and attach an explanatory statement to this form. |
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申請日期(Date
Of Application)
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(Diisi sesuai kenyataan) |
是否由其他人代填本申請表?(Was
this application filled in by another person on your behalf?)
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Yes No
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代填人姓名(Name)
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(Dikosongi)
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與申請人關系(Relationship
to Applicant)
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(Dikosongi)
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代填人住址(Address)
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(Dikosongi)
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是否由代理人代送本申請表?(Was
the application submitted by an agent?)
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Yes No
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DOMESTIC
KTP No.
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35.7810.150986.0003
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代理人姓名(Agent's
Full Name)
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Ivan Arista
(TEC Indonesia)
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與申請人關係(Relationship
to the Applicant)
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TEC Indonesia Staff
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代理人電話(Agent's
Telephone No.)
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081.2310.0679
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代理人住址(Agent's
Address)
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Jl. Karang Empat Timur I/ 19, Surabaya
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